The Pathology of Variation

Saturday, March 18, 2017

In medical training we have to learn about lots of things. That is one reason why it takes a long time to train a competent and confident clinician.

First, we learn the anatomy (structure) and physiology (function) of the normal, healthy human.

Then we learn about how this amazingly complex system can go wrong.  We learn pathology.  And we do that so that we understand the relationship between the cause (disease) and the effect (symptoms and signs).

Then we learn diagnostics – which is how to work backwards from the effects to the most likely cause(s).

And only then can we learn therapeutics – the design and delivery of a treatment plan that we are confident will relieve the symptoms by curing the disease.


The NHS is an amazingly complex system, and it too can go wrong.  It can exhibit a wide spectrum of symptoms and signs; medical errors, long delays, unhappy patients, burned-out staff, and overspent budgets.

But, there is no equivalent training in how to diagnose and treat a sick health care system.  And this is not acceptable, especially given that the knowledge of how to do this is already available.

It is called complex adaptive systems engineering (CASE).


Before the Renaissance, the understanding of how the body works was primitive and it was believed that illness was “God’s Will” so we had to just grin-and-bear (and pray).

The Scientific Revolution brought us profound theories, innovative techniques and capability extending tools.  And the impact has been dramatic.  Those who have access to this knowledge live better and longer than ever.  Those who don’t … don’t.

Our current understanding of how health care systems work is, to be blunt, medieval.  The current approaches amount to little more than rune reading, incantations and the prescription of purgatives and leeches.  And the impact is about as effective.

So we need to study the anatomy, physiology and pathology of complex adaptive systems like healthcare.

And just this week a prototype complex system pathology training system was tested … and it employed cutting-edge 21st Century technology: Pasta Twizzles.

The specific topic under scrutiny was variation.  A brain-bending concept that is usually relegated to the mystical smoke-and-mirrors world called “Sadistics”.

But no longer!

The Mists-of-Jargon and Fog-of-Formulae were blown away as we switched on the Light-of-Simulation and went exploring.

Empirically. Pragmatically.


And what we discovered was jaw-dropping.

A disease called the “Flaw of Averages” and its malignant manifestation “Carveoutosis“.


And with our new knowledge we opened the door to a previously hidden world of opportunity and improvement.

Then we activated the Laser-of-Insight and evaporated the queues and chaos that, before our new understanding, we had accepted as inevitable and beyond our understanding or control.

They were neither. And never had been. We were deluding ourselves.

Welcome to the Resilient Design – Practical Skills – One Day Workshop.

Validation Test: Passed.